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COMMUNITY PROFILE REPORT ©2011 North Florida Affiliate of Susan G. Komen for the Cure® 2011 Disclaimer: The information in this Community Profile Report is based on the work of North Florida Affiliate of Susan G. Komen for the Cure® in conjunction with key community partners. The findings of the report are based on a needs assessment public health model but are not necessarily scientific and are provided "as is" for general information only and without warranties of any kind. Susan G. Komen for the Cure and its Affiliates do not recommend, endorse or make any warranties or representations of any kind with regard to the accuracy, completeness, timeliness, quality, efficacy or non-infringement of any of the programs, projects, materials, products or other information included or the companies or organizations referred to in the report. 2 Acknowledgements We would like to extend a profound thank you to the organizations and community members who assisted with this effort. North Florida Affiliate Community Profile team members: Bruce Grob Executive Director Susan G. Komen for the Cure®, North Florida Affiliate Steven Meadows Intern Susan G. Komen for the Cure®, North Florida Affiliate Jeffry Will Executive Director Northeast Florida Center for Community Initiatives at The University of North Florida Tim Cheney Assistant Director Northeast Florida Center for Community Initiatives at The University of North Florida Molly Cranston Research Assistant Northeast Florida Center for Community Initiatives at The University of North Florida A special thank you to the following contributing partners: St. Vincent’s Hospital Baptist Health Baker County Health Department Clay County Health Department Duval County Health Department Nassau County Health Department Bosom Buddies of Jacksonville Volunteers in Medicine Sisters Network NEFL Samaritan Medical Clinic UF Shands Cancer Center Flagler Hospital Breast Cancer Support Group of St. Augustine The Way Free Medical Clinic, Inc. Legacy of Care Health Clinic We Care Clinic Agape Community Health Care Center Florida Cancer Data System (FCDS), Dept. of Health 3 Table of Contents Executive Summary .......................................................................................................................5 Introduction ..................................................................................................................................5 Demographic and Program Overview ..........................................................................................6 Health Systems Analysis ..............................................................................................................7 Quantitative/Qualitative Data Overview .....................................................................................7 Conclusions ..................................................................................................................................8 Introduction ..................................................................................................................................10 Affiliate History .........................................................................................................................10 Description of Service Area .......................................................................................................10 Purpose of the Report .................................................................................................................13 Breast Cancer Impact in Affiliate Service Area ........................................................................14 Methodology ..............................................................................................................................14 Overview of the Affiliate Service Area ......................................................................................15 Conclusions ................................................................................................................................19 Health Systems Analysis of Target Communities .....................................................................20 Overview of Continuum of Care ................................................................................................20 Methodology ..............................................................................................................................20 Partnerships and Opportunities ..................................................................................................21 Findings ......................................................................................................................................21 Breast Cancer Perspectives in the Target Area ........................................................................23 Methodology ..............................................................................................................................23 Conclusions ................................................................................................................................23 What We Learned. What We Will Do .......................................................................................24 Action Plan/Affiliate Priorities...................................................................................................24 Appendix A ...................................................................................................................................26 4 Executive Summary Introduction Susan G. Komen for the Cure® was established in 1982 by Nancy Brinker to honor the memory of her older sister, Susan G. Komen, who died from breast cancer at the age of 36. Nancy promised her dying sister that she would do everything in her power to end breast cancer forever. That promise is now Susan G. Komen for the Cure®, the global leader of the breast cancer movement. Today, Komen for the Cure is the world’s largest grassroots network of breast cancer survivors and activists. The North Florida Affiliate of Susan G. Komen for the Cure® was created in Duval County in 1995 to help raise awareness and funds for local breast health programs and education. Today, the North Florida Affiliate encompasses a broad geographic area that includes Duval County (the entire city of Jacksonville, Jacksonville Beach, Atlantic Beach, and Neptune Beach), and the four surrounding suburban and rural Affiliate counties - St John’s, Clay, Baker, and Nassau. This large service community area includes a very ethnic, cultural, and economically diverse population. North Florida Susan G. Komen continues to carry out the promise of saving lives and ending breast cancer forever by empowering people, ensuring quality care for all and energizing science to find the cures. We work toward this promise through the hard work of volunteers, one fulltime and two part time staff, and an eight member Board. We raise funds through our annual “Race for the Cure”, a “Walk for Awareness” event that targets some of Jacksonville’s culturally diverse community, a “Motorcycle for the Cure” event scheduled for May 2012, several third party events, an end-of-year appeal that includes a targeted “Circle for the Cure” invitation aimed at $1000 donors, etc. Our goal is to expand and diversify our support in order to expand and diversify our five county granting efforts. The Community Profile is a local needs assessment that is conducted every two years by every Komen Affiliate. The goal of the Community Profile is to gather information about the community for the purpose of identifying needs in services that must be addressed to improve breast health among members of the community and identifying the populations most in need of breast health services. It is used initially to identify the gaps between services that are currently provided and services that are needed. When reviewed annually, it can also be used to evaluate the impact the local grant programs are having on the status of breast health within our community. The Community Profile is a snapshot of the community, specifically looking at breast health and breast cancer: Demographics, such as population by age, race and income levels. Breast cancer statistics, such as screening, incidence and mortality rates, an assessment of current services for breast cancer screening and treatment in the community. Education levels of a population by county. A survey of the community’s beliefs and attitudes about breast cancer. 5 The Profile includes analysis of current statistical information, surveys from community key informants, medical professions, breast cancer patients and/or survivors. This information is instrumental in guiding our Affiliate’s direction and strategic planning through focusing on activities, such as grant making, fund raising and education outreach, so as to not duplicate programs already in place and focus our efforts on addressing unmet breast health and breast cancer needs. The Affiliate serves over 1,120,000 people, of whom approximately 51% are female. While St. Johns, Baker, Nassau and Clay Counties are predominantly white, Duval County is extremely diverse with almost 30% African American and 8% Hispanic or Latino. Baker County has over 18% of the population living below poverty level, with Duval County at 13.5%. Baker County has the highest percentage of Females 40+ without a Mammogram in the last (2009) reporting year. Baker and Duval Counties have the highest percentage of uninsured females. Nassau, Baker and Duval Counties have the highest breast cancer incidence and mortality rates. Based on these statistics we plan to focus our grant making in Duval, Baker and Nassau Counties. Demographic and Breast Cancer Statistical Overview Data collection for the North Florida Affiliate Community Profile began in April of 2011 and includes the North Florida Affiliate counties of Duval, Nassau, St. Johns, Baker and Clay. The Affiliate hopes to expand to include Alachua and Putnam Counties. The profile includes analysis of a variety of current statistical information, surveys from community key informants, medical professions, breast cancer patients and/or survivors. In order to reach a targeted understanding of the area it was necessary to break down the analysis to the state and county levels. 2009 and 2010 state demographic data and county demographic data were obtained from www.census.gov and www.factfinder.census.gov. County level cancer and breast cancer mortality and incidence rates were obtained from the National Cancer Institute’s State Cancer Profiles website at www.statecancerprofiles.cancer.gov. Thompson Reuters calculated breast cancer estimates using NCI’s Surveillance, Epidemiology and End Results (SEER) data. To supplement our research, we examined breast cancer mortality and incidence rates from the Florida Cancer Data System (FCDS). FCDS is Florida's legislatively mandated, populationbased, statewide cancer registry and can be located at http://fcds.med.miami.edu. From 2009 to 2011 the overall population for the Northeast Affiliate area increased. The biggest increases occurred in Nassau County (10.2 percent) and St. Johns County (14.6 percent), while Duval County experienced the lowest proportionate growth at 2.8 percent. The remaining counties, Baker and Clay, experienced an 8.1 and 8.7 percent population growth within the two year period. Although the average annual count for incidences of breast cancer increased slightly, the annual incidence rate dropped. The incidence count and rate for breast cancer (in-situ) increased slightly with the highest rates in Duval and St John’s Counties. In the 45-64 and 65 and above age groups, breast cancer incidences have all slightly declined, except among females 45-64 in Duval 6 County where it remains stable. While the 0-17 age group breast cancer incidence remain similar (all around 0.05), the 18-44 age group has experienced slight increases across the North Florida Affiliate area in the two year period from 2007 to 2009. After analyzing the counties with many variables (mortality, poverty, ethnicity/culture, incidence, late stage diagnosis, mammography rates, etc.), the Affiliate determined to focus on three counties within our service area. The purpose of this is to gain knowledge and understanding of the gaps, beliefs, issues of the population, the health systems assets and barriers and gain knowledge of the informants or people that work in these counties to get various perspectives on the issues surrounding the breast cancer continuum of care. Duval, Nassau and Baker counties had high incidence rates, breast cancer mortality, percentage of women over 40 who haven’t had a mammogram in the previous 12 months, poverty and amount of people who are uninsured. Each county is different in the ranking of these variables; however they stood out as higher than other counties in the variables that we have focused on. Programs and Services Overview The North Florida Affiliate area is home to an ample amount of medical care facilities and providers, but the same access to cancer care services is weakened by the physical location of those providers. The unbalanced distribution of infrastructure for cancer care in North Florida is revealed in the county’s mortality and incidence rates. Jacksonville, Florida is the largest city in land area in the state of Florida and the county seat of Duval County. According to the 2010 U.S. Census Report the total estimated population in the North Florida Affiliate area is over 1.35 million. Duval also has a total area of 918 square miles, which makes it difficult and time consuming for people to get around. As a result, transportation can be an additional barrier for those who live in the North Florida Affiliate area. Duval has a total of 12 hospitals and 59 clinics. In contrast, Nassau, St. Johns, Baker and Clay have a combined total of 6 hospitals and 32 clinics. St John’s has one hospital and 14 clinics, yet has a population of more than 190,000 people. Health Systems Analysis In order to address the needs of our service area, it is important to understand the barriers to care that women face. To do this involves identifying how a woman moves through the full circle of care from education and screening to diagnosis and treatment if necessary, and follow-up. This is called the continuum of care. In the North Florida Affiliate Counties the largest barrier to the progression of the breast cancer treatment continuum was either a lack of access to screening mammograms for the poor and underinsured, or very little in the way of follow up care for such patients. While Duval County has a few providers for the poor and underinsured, other counties in the area are not as well covered. Baker County had a Komen grant that allowed women to get breast cancer screenings performed; however, Baker County lacks accessible avenues for breast cancer treatment for poor and underinsured women. Aside from the resources available to all counties in the NE FL area, Clay County has no resources for providing breast cancer screening and treatment services to the poor and underinsured. Like Clay County, Nassau County does not have additional resources for providing breast cancer screening services for the poor and underinsured 7 and only one program was identified that provides treatment after diagnosis. While there are a couple of programs in St. Johns County where poor and underinsured women can obtain breast screening services, including one funded by a Komen grant, there is a lack of funds to help underinsured women diagnosed with breast cancer get treatment. Barriers to services included transportation and language issues. Very few transportation resources were mentioned for helping women get to screening and treatment in any of the counties. While all of the public health departments have access to interpreters or over the phone translation services, facilities in Baker County and some areas of the outlying counties have some issues with the ability to accommodate non-English speaking individuals. The WE CARE clinics in Duval County experience challenges because the clinics are operated mostly by volunteers. Quantitative Data Overview US Census data (both estimates and annual counts) presents a "snapshot" of the population of the target counties, outlining population levels, overall racial and age characteristics, and race/age breakdowns for women. Proprietary information from the UNF Center for Community Initiatives provides statistics on a variety of cancer-related incidence, treatment, and mortality rates, as well as other health measures. Qualitative Data Overview Quantitative and limited qualitative information on service providers in the North Florida Affiliate region was collected through a telephone survey to several (48) area service providers that were conducted by Komen interns. Due to staff and time constraints, we were not able to conduct comprehensive surveys or focus groups for this profile. Conclusion While the timeframe and methodology was limited, the statistics, quantitative survey information and qualitative phone information highlighted the need for the North Florida Affiliate to focus its primary health education and granting activities on Duval County (pop. 864,263), Nassau County (pop. 73,314), and Baker County (pop. 27,115). The information also highlighted the need for the North Florida Affiliate to spend time meeting and working with service providers in all five counties we serve. 2011 -2013 North Florida Affiliate Priorities 1. Reduce the barriers to screening and treatment especially for rural, urban core and AfricanAmerican women in our service area with the highest breast cancer mortality rates - Duval, Baker and Nassau Counties. Locate and support health care providers in these areas willing and able to perform mammograms at a reduced cost. Engage in a more thoughtful and comprehensive process starting in 2011 – clear methodology and full engagement of community - to identify service assets and needs, in 8 order to create a more clearly defined and informed granting process in 2012 and a more thorough and comprehensive Community Profile in 2013. Hold a grant writing workshop in early 2012 to solicit grants that address the barriers to screening and diagnostics for the medically underserved in our service area. 2. Locate and support transportation services that can provide assistance to those who cannot receive services due to lack of local availability and a means of transportation. 3. Education must include screening guidelines and community resources, i.e. where to get screening, financial aid, transportation, etc. Health care professionals also need this information as many are unaware of available programs. Support the M-Line program now being managed and staffed by Baptist Hospital and the Hill Breast Center. Develop and distribute community resource list to healthcare providers and consumers, including the M-line, throughout our Affiliate service area. 4. Culturally appropriate education is needed in our service area and needs to come from trained and trusted members of the various diverse communities. Conduct training workshops. 5. Breast cancer survivors’ needs are relative to their age and prognosis. There is a need for both mentoring support and peer-to-peer support. Partner with Bosom Buddies, the Women’s Center of Jacksonville and other area support networks to expand their reach and effectiveness. 9 Introduction North Florida Komen Affiliate The mission of Susan G. Komen for the Cure® is to eradicate breast cancer as a life-threatening disease by advancing research, education, screening and treatment. To help fulfill the promise to save lives and end breast cancer forever, the first ever North Florida Race for the Cure was held in Jacksonville Beach, Florida. Building on the success of the event, the North Florida Affiliate was created in 1995 to help raise awareness and funds for local breast health programs and education. Today, the North Florida Affiliate continues to carry out the promise of saving lives and ending breast cancer forever by empowering people, ensuring quality care for all and energizing science to find the cures. We are working toward this promise through the hard work of volunteers and survivors, board members and staff. The past two years have seen a significant transition for the North Florida Affiliate, culminating with the appointment of Dr. Bruce Grob as Executive Director in April of 2011. We also started a working partnership with the Northeast Florida Center for Community Initiatives (CCI) at the University of North Florida to assist in developing the Community Profile. CCI has the resources and expertise to help map the needs and assets unique to a community, agency, or program. Such an assessment provides the foundation from which tailored initiatives can be formed and implemented. CCI uses a variety of data gathering techniques for needs and assets assessments, such as telephone and door-to-door surveys, face-to-face interviews, focus groups, and community forums. The combination of these techniques assists the research team in painting the most comprehensive picture for stakeholders. Due to the change in Affiliate leadership and the resulting narrow window of time, the Community Profile presented here is necessarily limited in its scope. First, using US Census data (both estimates and annual counts) we present a "snapshot" of the population of the target counties, outlining population levels, overall racial and age characteristics, and race/age breakdowns for women. Second, using proprietary information from a variety of sources, we outline the latest statistics on a variety of cancer-related incidence, treatment, and mortality rates, as well as other health measures. The information for these components was primarily compiled for the report by CCI. The third component consists of information on service providers in the North Florida Region. The fourth section presents the results from a brief telephone survey conducted by Komen interns. Due to staff and time constraints, we were not able to conduct comprehensive surveys or focus groups for this profile. *We will be working with CCI to help carry out the full Profile in 2013. Description of Service Area Jacksonville is the largest city in land area in the state of Florida and the county seat of Duval County. The Greater Jacksonville Metropolitan Area consists of Duval County (Jacksonville and the cities of Jacksonville Beach, Atlantic Beach, Baldwin and Neptune Beach), Clay County, St. Johns County, Nassau County and Baker County. The total estimated population is over 1.12 10 million residents (2010 US Census). It is the fifth largest metropolitan area in the state of Florida, behind Miami, Tampa / St Petersburg / Clearwater, Orlando and West Palm Beach / Boca Raton. Jacksonville lines both banks of the St. Johns River, the state's longest river, which empties into the Atlantic Ocean about 20 miles from downtown. The St. Johns flows north for 310 miles before turning east to the ocean at Jacksonville. Jacksonville's deep-water port is the 14th largest in the U.S. and handles shipments from around the globe. Below is a map illustrating the counties in Florida. The five counties highlighted in aqua represent the counties covered by the North Florida Affiliate. The subsequent pages include a brief history and description of each of the counties in the North Florida Affiliate region. Duval County was created in 1822. It was named for William Pope Duval, Territorial Governor of Florida from 1822 to 1834. When Duval County was created (on the same day as Jackson County) it covered a massive area, from the Suwannee River on the west to a line running from Jacksonville to the mouth of the Suwannee River on the east. On October 1, 1968 the government of Duval County was consolidated with the government of the City of Jacksonville, although the Duval County cities of Atlantic Beach, Baldwin, Jacksonville Beach, and Neptune Beach are not included in the corporate limits of Jacksonville, and maintain their own municipal governments. The 2010 U.S. Census Bureau’s Decennial Census reported that Duval County had a total population of 864,263 with an average household size was 2.47. 11 Duval County has a total area of 918 square miles, of which 774 square miles consists of land and 145 square miles is water (U.S. Census Bureau, 2005-07 American Community Survey). Nassau County was created in 1824. It was named for the Duchy of Nassau in Germany. Nassau County’s economy is very diverse, ranging from agricultural activity (mostly in the form of tree farms) in the west and central areas, to a variety of activities closer to Amelia Island. Historically, tree farming, trucking, and pulp production have characterized a large portion of the local economy. However, extensive growth is occurring in the outlying small towns in the rural western area. The 2010 U.S. Census Bureau’s Decennial Census reported that Nassau County had a total population of 73,314 with an average household size was 2.53. St. Johns County was created in 1821 and was named after St. John the Baptist. St. Johns County and Escambia County were Florida's original two counties with the Suwannee River being the boundary between the two. St. Johns County is located in northeastern Florida. According to the U.S. Census Bureau, the county has a total area of 821 square miles (2127km²) consisting of 609 square miles (1,577 km²) of land and 212 square miles of water. St. Johns County's main economic base is tourism. The 2010 U.S. Census Bureau’s Decennial Census reported that St. John’s County had a total population of 190,039 with an average household size was 2.49. Baker County was established in 1861 and named for James McNair Baker, a judge and Confederate Senator. It is located in MacClenny, Florida and extends to the Okefenokee Swamp. While primarily rural, the county is included in the Jacksonville Metropolitan area. The 2010 U.S. Census Bureau’s Decennial Census reported that Baker County had a total population of 27,115 with an average household size was 2.82. Clay County was created on December 31, 1858, from a section of Duval County. Its name is in honor of Henry Clay, a famous American statesman. Clay County was once a popular destination for tourists visiting from the northern states. The therapeutic, warm springs and mild climate were major draws for visitors. Steamboats brought them to various hotels in Green Cove Springs. The military has also played an important role in Clay County history. In 1939, Camp Blanding opened on Kingsley Lake in central Clay County. According to Claycounty.gov the Florida National Guard developed this 28,000 acre complex. During World War II, it trained over 90,000 troops and became the fourth largest 'city' in the state. Clay County is also a popular choice of residence for military personnel who are stationed on bases in nearby Duval County. The 2010 U.S. Census Bureau’s Decennial Census reported that Clay County had a total population of 190,865 with an average household size was 2.80. 12 Community Profile: Purpose of Report The community profile is a local needs assessment that is conducted every two years by every Komen Affiliate. The goal of the Community Profile is to gather information about the community for the purpose of identifying needs in services that must be addressed to improve breast health among members of the community and identifying the populations most in need of breast health services. It is used initially to identify the gaps between services that are currently provided and services that are needed. When reviewed annually, it can also be used to evaluate the impact the local grant programs are having on the status of breast health within our community. The Community Profile is a snapshot of the community, specifically looking at breast health and breast cancer. The profile can include: Demographics, such as population by age, race and income levels. Breast cancer statistics, such as screening, incidence and mortality rates, an assessment of current services for breast cancer screening and treatment in the community. Education levels of a population by county. A survey of the community’s beliefs and attitudes about breast cancer. The North Florida Affiliate Community Profile encompasses a broad geographic area that includes Duval County (the entire city of Jacksonville, Jacksonville Beach, Atlantic Beach, and Neptune Beach), and the four other suburban and rural Affiliate Counties - St John’s, Clay, Baker, and Nassau. This large community area also has a diverse population. The profile should include analysis of a variety of current statistical information, surveys from community key informants, medical professions, breast cancer patients and/or survivors. This information is instrumental in guiding our Affiliate’s activities, such as grant making, fund raising and education outreach, so as to not duplicate programs already in place and focus our efforts on addressing any unmet breast health and breast cancer needs. 13 Demographic and Breast Cancer Statistics Data Source and Methodology The North Florida Affiliate demographic “estimates” for female population by ethnicity, age, and county were obtained from Thomson Reuters. *As indicated, we are aware that Thomson Reuters has limitations due to the fact that the demographics are estimates. In order to reach a targeted understanding of the area it was necessary to break down the analysis to the state and county levels. 2009 and 2010 state demographic data and county demographic data were obtained from www.census.gov and www.factfinder.census.gov. County level cancer and breast cancer mortality and incidence rates were obtained from the National Cancer Institute’s State Cancer Profiles website at www.statecancerprofiles.cancer.gov. Thompson Reuters calculated breast cancer estimates using NCI’s Surveillance, Epidemiology and End Results (SEER) data. To supplement our research, we examined breast cancer mortality and incidence rates from the Florida Cancer Data System (FCDS). FCDS is Florida's legislatively mandated, populationbased, statewide cancer registry and can be located at http://fcds.med.miami.edu. To further understand geographic healthcare needs and to compare the number of hospitals, clinics and medical physicians in the North Florida Affiliate area to the mortality and incidence rates, we acquired information from www.FloridaHealthFinder.gov. For additional information regarding educational levels of a population by county, statistics were obtained from the Florida Department of Education’s Data Publications & Reports, Graduation Rates by District, as of 1/09/09 at www.fldoe.com and the National Center for Education statistics at www.nces.ed.gov/. To offer additional demographic information in each of the five counties located in the North Florida Affiliate area, individual county websites were explored. 14 Duval County Our largest service area with a population of 864,263, Duval County is primarily urban and our most diverse service area with almost 30% of the population African American, 8% Hispanic and 4% Asian. 13.3 % of individuals live below the poverty level. 51.5% of the population is female. Research from the U.S. Department of Education suggests that education level is a measure of community health. Duval County has a high school graduation rate below 70% which is one of the lowest in the State of Florida as well as the Country. Female Population by Ethnicity and Age Source: U.S. Census Bureau’s 2005 – 2009 American Community Survey 5–Year Estimates by County produced by American FactFinder Ethnicity White Hispanic Black Asian Pacific American Indian All other 2009 Pop. 271,261 25,103 130,764 16,161 % Females (0-19) 22.8 33.6 30.7 25.4 % Females (20-29) 14.8 19.3 16.7 16.4 % Females (30-44) 20.8 24.0 22.2 24.9 % Females (45-54) 15.4 10.8 13.5 13.5 % Females (55-64) 11.8 6.1 8.2 10.5 % Females (65+) 14.5 6.3 8.7 9.3 1,048 17.5 13.5 27.5 21.2 14.5 5.9 17,120 45.3 17.9 21.5 7.6 4.4 3.2 Nassau County Nassau County is both suburban and rural with a population of 73,314 and is predominantly white (90%). 50.7% of the population is female. Female Population by Ethnicity and Age Source: U.S. Census Bureau’s 2005 – 2009 American Community Survey 5–Year Estimates by County produced by American FactFinder Ethnicity White Hispanic Black Asian Pacific American Indian All other 2009 30,430 678 3010 381 136 % Females 23.1 24.1 29.2 23.6 52.2 % Females 10.6 19.2 10.7 4.2 0.0 % Females 19.3 19.2 21.9 19.4 19.9 % Females 15.9 17.4 13.2 28.9 13.2 % Females 14.6 5.0 10.9 13.9 14.7 % Females 16.3 15.0 14.1 10.0 0.0 341 40.5 7.3 18.5 17.3 16.4 0.0 30,430 23.1 10.6 19.3 15.9 14.6 16.3 15 St. Johns County The second largest County in our service area, St Johns County is suburban with a population of 190,039, St Johns County is 90% white, almost 6% African American and 5% Hispanic. 51.4% of the population is female. Female Population by Ethnicity and Age Source: U.S. Census Bureau’s 2005 – 2009 American Community Survey 5–Year Estimates by County produced by American FactFinder Ethnicity White Hispanic Black Asian Pacific American Indian All other 2009 Pop. 79,320 3,893 5,673 1,757 % Females (0-19) 22.9 34.6 30.2 26.1 % Females (20-29) 10.1 12.1 13.4 3.5 % Females (30-39) 19.5 25.3 23.2 39.7 % Females (40-49) 16.8 12.6 11.6 14.1 % Females (50-59) 13.9 7.8 9.2 6.3 % Females (65+) 16.8 7.6 12.5 10.4 250 30.8 27.6 8.0 6.8 20.4 6.4 2,088 41.6 13.6 18.5 11.9 5.7 8.7 Baker County Baker County is primarily rural and has a population of 27,115, with 83% white, and 14% African American. 18.2% live below the poverty level. 47.8% of the population is female. Female Population by Ethnicity and Age Source: U.S. Census Bureau’s 2005 – 2009 American Community Survey 5–Year Estimates by County produced by American FactFinder Ethnicity White Hispanic Black Asian Pacific American Indian All other 2009 Pop. 10,506 256 1,308 51 % Females (0-19) 29.1 70.7 35.9 31.4 % Females (20-29) 13.3 8.6 21.9 45.1 % Females (30-39) 19.5 0.0 13.5 0.0 % Females (40-49) 14.2 0.0 11.6 0.0 % Females (50-59) 11.5 13.3 9.6 0.0 % Females (65+) 12.3 7.4 7.5 23.6 8 0.0 0.0 100.0 0.0 0.0 0.0 278 41.7 21.6 0.0 24.8 0.0 11.9 16 Clay County Clay County stretches from urban to rural with a large military population housed on and around the Navel Air Station. Clay Count has a population of 190,865, with 81% white, 10% African American, and 7.7% Hispanic. 51% of the population is female. Female Population by Ethnicity and Age Source: U.S. Census Bureau’s 2005 – 2009 American Community Survey 5–Year Estimates by County produced by American FactFinder Ethnicity White Hispanic Black Asian Pacific American Indian All other 2009 Pop. 75,431 6,078 8,815 2,992 % Females (0-19) 26.9 36.8 37.4 27.0 % Females (20-29) 10.9 13.2 11.8 9.7 % Females (30-39) 21.3 25.7 25.0 24.9 % Females (40-49) 16.0 11.5 13.7 15.9 % Females (50-59) 12.4 6.5 6.7 14.4 % Females (65+) 12.5 6.4 5.5 8.0 363 15.4 15.7 30.9 14.0 13.2 10.7 3,656 47.5 14.1 18.3 10.3 4.2 5.6 Breast Cancer Findings Breast Cancer Sites – Incidence Based on NCI’s State Cancer Profiles Incidence Rate Report for Florida by County, including all races, female population and all ages, breast cancer incidence rates are as follows: State/County Annual Incidence Rate Florida (State) United States Duval County Nassau County St. Johns County Baker County Clay County 112.5 120.6 127.6 110.3 125.8 116.4 121.7 Average Annual Count 12,603 ** 560 44 126 ** 109 **Data not provided because it did not meet USCS data quality standards for one or more years during the rate period of data collection. 17 Breast Cancer Sites - Mortality Based on NCI’s State Cancer Profiles Death Rate Report for Florida by County, death years (per 100,000) through 2007 including all races, female population, all ages and recent trends breast cancer rates are as follows: State/County Annual death Rate Average Deaths per Year Recent Trend Florida (State) United States Duval County Nassau County St. Johns County Baker County Clay County 23.0 25.0 28.8 26.1 25.6 2,654 41,319 121 10 24 3 or fewer 18 falling ↓ falling ↓ falling ↓ stable → falling ↓ ** stable → 23.2 **Data is too sparse to provide stable estimates of annual rates needed to calculate trends. Breast Cancer Deaths and Mortality Rates by County for the North Florida Affiliate area Ranked by Mortality Cases County 2009 Female Population Mortality Cases Mortality Per 100k Population Rate Duval Nassau St. Johns Baker Clay 458,780 35,918 93,863 12,403 95,610 93 8 18 2 16 20.20 22.62 19.14 19.41 16.36 Mammography Screenings Females 40+ without a Mammography Area: North Florida Affiliate 2009 Female Population 40+ County 2009 Female Pop. 40+ %No Mammogram last 12 mos. % Chose not to Duval Nassau St. Johns Baker Clay Total 213,181 18,723 49,671 5,542 45,816 332,933 37.1% 34.8% 34.3% 38.1% 35.3% 36.3% 5.6% 5.9% 5.7% 6.6% 5.7% 5.6% % Didn’t have time 9.9% 9.6% 9.2% 10.3% 8.9% 9.6% % Didn’t need % Have scheduled % Other reasons 2.8% 2.7% 2.8% 2.6% 2.9% 2.8% 3.2% 3.7% 3.3% 3.8% 3.7% 3.3% 15.3% 12.8% 13.0% 14.6% 13.9% 14.6% 18 Number of Uninsured Females by County North Florida affiliate area Ranked by 2009 Female Population County Duval Nassau St. Johns Baker Clay 2009 Female Population 458,780 35,918 93,863 12,403 95,610 Uninsured Females 18-64 (Pop.) 81,944 4,056 11,580 2,485 9,359 Uninsured Females % 21.3% 13.5% 14.6% 24.0% 11.7% Source: Thomson Reuter’s Overview: What the Data Shows Duval County has the highest annual incidence rate of breast cancer in our service area; St Johns County has the second highest incidence rate; Clay County third. Nassau County has the highest breast cancer death and mortality rate; Duval County has the second highest rate; Baker County third. Baker County has the highest percentage of 40+ females without a Mammogram in the previous 12 month period; Duval second; Clay County third. Baker County has the highest level of poverty; Duval County has the second highest level of poverty; Nassau County third. Baker County has the highest percent of uninsured females at 24.0 percent; Duval County is second; Nassau County third. Based on this statistical information, North Florida Susan G. Komen will focus its primary activities on Duval, Baker and Nassau Counties, while continuing to provide education and where possible resources, to targeted projects in St. Johns County and Clay County. 19 Health Systems Analysis of Target Communities Continuum of Care In order to address the needs of our service area, it is important to understand the barriers to care that women face. To do this, we must see how a woman moves through the full circle of care from education and screening to diagnosis and treatment if necessary. This is called the continuum of care, illustrated in Figure 9. The continuum begins with breast health education and screening guidelines. Next, one must actually be screened and receive appropriate follow-up. For most that simply means continuing regular screenings. However, for women (and men) with a suspicious mass, Figure 9. The breast health continuum of care. Susan G. Komen for the Cure, 2011 Community diagnostics and treatment may follow. Treatment may Profile Guide, 2010. include surgery, radiation, and chemotherapy. After the initial treatment, there may be years of post-treatment care, which can include additional cancer preventive drugs and follow-up tests. These breast cancer survivors will also need to continue regular breast cancer screenings. Each step in this continuum is essential, and missing one piece can substantially impact one’s chance of survival. When looking at the health systems of the target communities, the focus is on the gaps in care due to their impact on the mortality rates of that community. Programs and Services The Komen North Florida affiliate has partnered with many agencies to provide necessary breast health education and screening services in the North Florida area. Our Affiliate has funded grants for screening services in all counties and provides free breast health literature to local organizations, schools, clinics and churches. We currently do not fund any grants for patient transportation, patient navigators or breast cancer treatment. Data Source and Methodology All qualitative data was collected via phone interviews with breast health service providers in the community which cover the service categories of screening, treatment, aid (financial and otherwise), program, education, and support group. Prior to the calls being made, a database was created by compiling resources in Baker, Clay, Duval, Nassau, and St. Johns counties from the Komen grantee lists, previous Komen resource lists, and simple internet searches for resources in North Florida Komen Affiliate’s service area. The calls were made from this list and it was updated throughout the calling process. Questions were based off of Support Document F – Sample Provider Survey Questions provided on the Susan G. Komen Affiliate Corner. The questions were tailored to gather information about gaps in the breast cancer continuum of care, to identify other resources in the area, and to gather suggestions of improvement on the current breast healthcare system. The sampling method used was convenience, meaning that the service providers were only contacted if they had a phone by which they could be contacted and if they were available to talk. A minimum of three calls were made to the service providers, and messages were left if they were unable to be contacted. 48 Providers were called, 28 responded. *Please see Appendix A for the list and description of programs and services. 20 Partnerships and Opportunities North Florida Komen has established some alliances within the communities it serves through grants and collaborative work. Because of past funding challenges and the geographic spread of our service area, North Florida grants do not currently serve every county with screening and diagnostic services. Grants for education are in targeted communities. Several partnerships formed through our grants need to be revisited and, where needed and effective, re-cultivated. Our partners have included the major hospital systems, as well as community hospitals and clinics. The weakest partnerships have been in our rural counties and with primary care physicians. Partnership opportunities should include churches and collaborative community groups. These groups have a vested interest and strong ties in the local community. Several churches throughout the service area already partner with the affiliate on Pink Sunday as well as other educational programs. Another partnership opportunity is through the colleges and universities in our service area. Many of them have students studying public health or health promotion. Partnering with them would allow for additional outreach. Partnership opportunities also exist with the medical community, including those not directly breast health related. Findings In most of the counties covered, it was found through our statistical data and through our phone survey of service providers that the largest barrier to the progression of the breast cancer treatment continuum was either a lack of access to screening mammograms for the poor and underinsured or that there was very little in the way of follow up care for such patients. These findings were also anecdotally reinforced by the challenges most often noted by our M-Line staffers. (The M-Line or Mammography Line is a toll free number that can be called by women who need help finding and paying for a Mammogram. North Florida Susan G. Komen staffs the M-Line and makes referrals.) There are programs in the area, however, attempting to address these issues. For instance, women in all counties covered by the NE FL Komen Affiliate have access to the Florida Breast and Cervical Cancer Area Reduction Program. With this program, women 50-64 years old who are within 200 percent of the poverty level and have no insurance are provided with breast exam, mammograms, and diagnostic follow up. Upon receiving a positive diagnosis, the women are referred to Medicaid for eligibility determination. Availability of this service depends on its funding and may be accessed through the local health departments. Some financial support is provided for those in need through The Donna Foundation, which is partnered with Catholic Charities. The Donna Foundation provides temporary financial aid to women in all counties covered by the NE FL Komen Affiliate, but only to women who are undergoing treatment for breast cancer. In addition to these services, women lacking financial resources and health insurance in Duval County have access to other providers. For example, Shands, Volunteers in Medicine (Duval only), and the WE CARE clinics (Duval only) provide both screenings and follow up care for the 21 poor and underinsured. The WE CARE clinics are staffed by volunteer doctors and therefore have irregular hours at times. Physical distance to such services remains an issue in Duval. In Baker County, women were able to get breast cancer screenings performed through a Komen grant. Komen was unable to fund the program in 2011-2012. Women could access this service though the Baker County Health Department, and were then referred to Frasier Hospital where they can access routine diagnostic mammograms and breast ultrasound. There is a current lack of accessible avenues for breast cancer treatment for poor and underinsured women. The routes that poor and underinsured women must take to access breast cancer treatment are through Medicaid, research projects at Mayo, or physicians who accept self-pay. It was mentioned that an issue with accessing Medicaid is that there is no representative in the county, so the only access is through the hotline which is not user friendly. Aside from the resources available to all counties in the NE FL area, Clay County has no resources for providing breast cancer screening and treatment services to the poor and underinsured. Like Clay County, Nassau County does not have additional resources for providing breast cancer screening services for the poor and underinsured. There is a program called “Nassau CMIT program” for Nassau residents below 110 percent of poverty level and have no insurance. Women who have been diagnosed can use this resource to get treatment. In St. Johns County, women 40-65 years old can access breast cancer screening through a Komen grant. Also, residents within 150 percent of the poverty level and with no insurance can get mammography vouchers for Flagler Hospital through the St. Johns County Health Department. Once women are diagnosed with breast cancer, there is a lack of funds to help these underinsured women get treatment. Additional barriers to services include transportation and language issues. Very few transportation resources were identified for helping women get to screening and treatment in any of the counties. Transportation can be challenging particularly for those with limited financial resources and residing in areas lacking efficient public transportation. The American Cancer Society, along with its other programs, has the Road to Recovery program in which cancer patients may receive transportation to and from treatment. This program is volunteer-based, so sometimes there are not volunteers available to give these rides. In cases where there are no volunteers available to give rides, gas cards are given to pay for gas costs. While all of the public health departments have access to interpreters or over the phone translation services, facilities in Baker County and some areas of the outlying counties have some issues with the ability to accommodate non-English speaking individuals. Some of the WE CARE clinics in Duval County experience challenges as well because the clinics are operated mostly by volunteers. 22 Breast Cancer Perspectives in the Target Communities As previously indicated, due to staff and time constraints, we were not able to conduct comprehensive surveys or focus groups with the “target communities” for this profile. The information in this section is extracted from the 2009 Community Profile. We have included it here to provide context for future research. The 2011 statistical and quantitative data, along with the limited qualitative phone information obtained in our service provider calls, indicates that there has been little change since this 2009 data was collected. The 2011 statistical and quantitative data, and the limited qualitative phone information obtained in our service provider calls, also highlighted the need for the North Florida Affiliate to start early and spend more time in the future meeting with service providers and recipients in all five counties we serve. The (2009) North Florida Affiliate assessment included the collection of key informant, provider, and patient resources. Inventory data was collected by utilizing current resources, which included Komen’s Pink Sunday database. A database created by researching North Florida’s white page phone directory for a listing of all churches by zip code, then mailing out forms to solicit their participation in our Pink Sunday Program. In agreeing to participate, these churches would have access to breast health literature and/or public speakers. For additional resources we reached out to local survivor groups, local county health departments, low-income health clinics, hospitals, including the local military naval hospital as well as Komen grantees. To further understand the needs and issues facing the population of North Florida, we solicited people who had contacted our mammogram hotline requesting breast health information or services to determine the overall experience of using this resource. Another important resource was local breast cancer survivor support groups. Many of these groups distributed the surveys or directed survivors to the Affiliate’s online electronic survey. Twelve hundred surveys were sent out across the five counties that encompass the North Florida Affiliate. An astounding twenty percent were completed and returned giving us greater insight into the assets and the gaps in the North Florida area. The surveys consisted of a mixture of closed and open ended questions and were implemented using the online survey tool SurveyMonkey. The surveys contained questions pertaining to demographics, access to care, health support, and barriers that prevented seeking or obtaining breast health services and financial support. Conclusions: What We Learned. The 2011 statistics and quantitative data analyses are supported by the 2009 qualitative (survey and focus group) information, and by the limited 2011 service provider phone survey data. The gaps in care leading to high mortality rates continue to be the result of a lack of services, resources and education. This remains especially true in Duval, Baker and Nassau Counties. Low-income and lack of insurance (Duval and Baker Counties) remain the major obstacles to screening and treatment. 23 The shortage of health care providers is of particular concern in rural communities because, in many cases, people have to travel for their medical care. Transportation then becomes an issue, as does the added expense of gas and lost wages. This is a concern for both the insured and uninsured. The lack of local services also affects the problem of time because rural women often travel an hour or more one way to reach a medical facility. This may mean an all day trip plus lost wages. Many who work are unable to get the time off, and most medical facilities are not open during the hours that women are not working. Again, with limited data, but consistent with other Affiliate Profiles in similar service areas, healthcare providers see the need to educate all women about the importance of mammograms; healthcare recipients agree but also see the need to educate health care professionals. There is, for example, confusion about current screening recommendations. Both medical professionals and the general public need more information about available resources. These resources include financial aid, transportation, and local agencies providing outreach services. What We Will Do: Selecting Affiliate Priorities We believe that all people deserve equal access to quality care, regardless of race or socioeconomic status. The medically underserved are of particular concern, and different populations have different barriers. Our goal is to reduce barriers to screening and treatment. Our first priority, to provide equal access to quality testing, care and treatment to the medically underserved, was determined by the high mortality rates seen in rural areas and the urban core. Because the Duval County urban core area has such a large African American population, this priority will address both groups. Education is a second priority. For both providers and the public the primary need is information about available services. Nutrition and healthy lifestyle education is also needed for all populations. To be effective, education must be culturally appropriate for the audience. The affiliate is committed to providing support for all phases of breast cancer, including long term survival. For this reason, the third priority addresses the unique set of issues survivors face. As survivors live longer, their needs evolve. Those needs include emotional support specific to their situation, as well as health care guidance for all. Affiliate Priorities 1. Reduce the barriers to screening and treatment especially for rural, urban core and AfricanAmerican women in our service area with the highest breast cancer mortality rates - Duval, Baker and Nassau Counties. Locate and support health care providers in these areas willing and able to perform mammograms at a reduced cost. Engage in a more thoughtful and comprehensive process starting in 2011 – clear methodology and full engagement of community - to identify service assets and needs, in order to create a more clearly defined and informed granting process in 2012 and a more thorough and comprehensive Community Profile in 2013. Hold a grant writing workshop in early 2012 to solicit grants that address the barriers to screening and diagnostics for the medically underserved in our service area. 24 2. Locate and support transportation services that can provide assistance to those who cannot receive services due to lack of local availability and a means of transportation. 3. Education must include screening guidelines and community resources, i.e. where to get screening, financial aid, transportation, etc. Health care professionals also need this information as many are unaware of available programs. Support the M-Line program now being managed and staffed by Baptist Hospital and the Hill Breast Center. Develop and distribute community resource list to healthcare providers and consumers, including the M-line, throughout our Affiliate service area. 4. Culturally appropriate education is needed in our service area and needs to come from trained and trusted members of the various diverse communities. Conduct training workshops. 5. Breast cancer survivors’ needs are relative to their age and prognosis. There is a need for both mentoring support and peer-to-peer support. Partner with Bosom Buddies, the Women’s Center of Jacksonville and other area support networks to expand their reach and effectiveness. Northeast Florida still faces significant challenges “getting out the word” on Breast Cancer and removing barriers to screening, testing and treatment. While we did see some decreases in the death rates for breast cancer in most counties in the service area, the rate was still significantly higher than the US overall average. With the significant economic problems facing the Northeast Florida region, and the continued high rates of uninsured women in the population, it is particularly important for North Florida Susan G. Komen to make possible equal access to quality testing, care and treatment to the medically underserved. The past two years have been challenging for the Northeast Florida Affiliate. This Community Profile was developed through a fledgling partnership with the Northeast Florida Center for Community Initiatives at UNF. Our goal is that through the collaborative efforts of CCI and the Northeast Florida Affiliate, a more thorough and comprehensive Community Profile will be produced and submitted for the 2013 report. 25 APPENDIX A Programs and Services Agency for Health Care Administration- Florida Medicaid In Florida, the AHCA develops and carries out policies related to the Medicaid program, which provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. http://www.fdhc.state.fl.us/Medicaid American Cancer Society (Duval, Clay, and Beaches Units) The American Cancer Society is a nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer through research, education, advocacy, and service. Programs provided to Northeast Florida include; Reach to Recovery and Road to Recovery. www.cancer.org Baker County Health Department http://www.bakercountyhealth.org/ Baptist Health Centers (Downtown Jacksonville, Jacksonville Beaches, South Jacksonville, and Nassau) Baptist Health Imaging Centers provide women a range of preventive, diagnostic, medical/surgical treatments, including mammography and imaging, as well as bone density testing. http://www.e-baptisthealth.com/ Beaches Cancer Support Group This support group has been established for over 5 years, and is available for any and all survivors, family members, friends and caregivers. Bosom Buddies of Amelia Island Support and education program for breast cancer survivors and women at high risk. 5:50 PM, first Wednesday, Fernandina Beach Police Department. Bosom Buddies, Women’s Center of Jacksonville Support and education program for breast cancer survivors and women at high risk. 7:00PM8:30PM Mondays; 10:00AM-11:30AM third Thursday at the Women’s Center of Jacksonville. Breast Cancer Support Group (Jacksonville) Presented by Mayo’s Breast Clinic and the Pink Sisters and Friends, 6:30-8:00 PM at the Jacksonville Mayo clinic. Breast Cancer Support Group (St. Augustine) 7:00 PM first Tuesday, Flagler Hospital. 26 Buddy Check 12 Awareness program in which women are encouraged to have a “buddy” who they will remind to do their monthly breast exam on the 12th of each month. Bust Busters, Inc. Cancer Resources and Support Group Cancer Survivors and their families and/or caregivers encounter many difficult issues. Come to these meetings to gain new insights, share ideas on how to cope, and meet others also facing your challenges. At each meeting, a specific topic will be covered with time following for general discussion. Cancer Survivors Network (ACS) www.cancer.org Catholic Charities Bureau of Northeast Florida This organization has teamed with the Donna Deegan Foundation to provide funds for women going through breast cancer treatment. http://www.ccbjax.org/ Christ the King Medical Clinic at South Jacksonville Family Health Clinic (WE CARE clinic) City Rescue Mission (WE CARE clinic) http://www.cityrescue.org/ Clay County Health Department Donna Deegan Foundation This organization has teamed with Catholic Charities Bureau of Northeast Florida to provide funds for women going through breast cancer treatment. http://www.donnahickenfoundation.org/ Duval County Health Department http://www.dchd.net/ Flagler Hospital Has an imaging center with mammogram, breast biopsy, and breast MRI services. It also has a cancer center for treatment. http://www.flaglerhospital.org/ Florida Breast & Cervical Cancer Early Detection Program The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as administered by the Centers for Disease Control and Prevention (CDC) funds the Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP). The NBCCEDP was created in response to the Breast and Cervical Cancer Mortality Act of 1990; Public Law 101-354. The FBCCEDP has been awarded funding by the CDC since 1994. The grant is administered through the central office and 16 lead County Health Department (CHD) regional coordinators manage service provision in the counties across the state to assure statewide access. The lead counties are: 27 Brevard, Broward, Duval, Escambia, Gadsden, Hillsborough, Jackson, Leon, Manatee, MiamiDade, Osceola, Pasco, Pinellas, Putnam, Seminole, and Volusia. http://www.doh.state.fl.us/family/cancer/bcc/index.html Frasier Hospital Provides routine, diagnostic mammograms and breast ultrasound. http://bcmedsvcs.com/ In the Pink… A Boutique for Women Living with Cancer One stop shop for women dealing with any stage of cancer, and any type. Post surgical garments, mastectomy bras and prostheses, lymphadema compression garments, wigs, scarves, gift items, 2x per week free yoga www.jaxinthepink.com Hanger Prosthetics and Orthotic http://www.hanger.com/Pages/default.aspx Healing Hands Medical Ministry (WE CARE clinic) http://westjaxoutreach.org/healingHands.html HOPE Women’s Support Group HOPE is a support group for women survivors of any cancer. This group meets on the second Tuesday of each month from 7:00 pm – 9:00 pm at the Orange Park Medical Center Legacy of Care Health Center, Inc. (WE CARE clinic) M-Line This is a directory program managed by North Florida Susan G. Komen. Women 40+ with no insurance may call and see if they qualify for free mammograms. They will be referred to certain agencies based on their location, health and financial circumstances. . Medical Care Products Inc. http://www.ostomymcp.com/index.html Memorial Breast Center Comprehensive, compassionate care, including MRI and other advanced diagnostic and screening technology. Personal service of a breast nurse navigator to support and guide patients and family. Multidisciplinary team-approach to coordinate the best available treatment options. Advanced reconstructive surgery technology. Information about ongoing cancer clinical trials and new treatment options. Access to prevention and early detection programs, cancer education, and support services. Ongoing monitoring and improvements in cancer care, such as lymph edema prevention and advanced reconstructive surgery options. http://memorialhospitaljax.com/our-services/breast-center.dot Mission House Medical Center (WE CARE clinic) http://www.missionhousejax.org/medical_services.htm 28 Muslimcare Clinic of Jacksonville (WE CARE clinic) http://www.icnef.org/muslimcare/index.html Nassau County Health Department www.nassaucountyhealth.org Orange Park Medical Center: Breast Center The breast center services include digital screening and diagnostic mammography, computeraided detection, breast ultrasound, galcatography, breast MRI, stereotactic, ultrasound and MRI guided breast biopsies, screening breast MRI according to the American Cancer Society guidelines, pre-surgical needle localizations, and sentinel node imaging. http://orangeparkmedical.com/our-services/breast-center.dot Orange Park Cancer Center http://www.foa.cc/about-us/our-locations/orange-park-cancer-center Ribbons & Roses Breast cancer support through education programs open to military personnel and their dependents. Access to Ribbons & Roses on base requires military identification. http://www.med.navy.mil/sites/nhjax/Pages/default.aspx Riverside Imaging Center (Signet Diagnostic) Screening and diagnostic mammography, breast ultrasound, most advanced breast MRI in region, biopsies stereotypic, ultrasound guided, and MRI guided http://www.signetdiagnostic.com/ Shands Jacksonville, University of Florida: Breast Center The Shands Jacksonville Breast Health Center offers advanced screening, diagnostic care, education and treatment. The University of Florida physicians at the Breast Health Center provide a multidisciplinary, team-based approach to comprehensive care, from annual mammograms to a wide array of advanced treatment options. They specialize in high-risk assessments and provide consulting and monitoring for patients at risk for breast cancer. Throughout the process, the breast health team provides information and support, as well as a second opinion service to review original pathology slides or mammography films. The team helps patients understand their diagnosis and treatment options to ensure they are making the best possible decisions for their care. http://jax.shands.org/hs/breast-cancer/ Signet Diagnostic Imaging Centers Multiple locations in Duval, and one in Clay. http://www.signetdiagnostic.com/ Sister’s Network NEFL Sisters Network is an African American survivorship organization focused on raising awareness of breast health and breast cancers through advocacy and community work. This group provides many educational opportunities for the community, such as speaking engagements, participation 29 in health fairs, and providing quarterly educational forums with professional speakers in the healthcare community. Sisters Network of NEFL also participates in annual events such as the Fall Symposium in September, and the Pink Ribbon Campaign in October. The support group is available for survivors, caregivers, family and friends. http://www.sistersnetworkinc.org/index.html South Jacksonville Family Health Center DCHD clinic. It provides clinical breast exams along with other services. http://www.dchd.net/southjax.htm St. Johns County Health Department http://www.stjohnschd.org/ St. Vincent’s Healthcare Includes St. Luke’s Hospital and St. Vincent’s Medical Center. They have breast health diagnostic services, and the mobile mammography unit. There is also a cancer center for treatment. http://www.jaxhealth.com/ St. Vincent Depaul Society http://www.svdpusa.org/ Trinity Rescue Mission (WE CARE clinic) http://www.trinityrescue.org/ Volunteers in Medicine Provide services, screenings, mammograms, (40+ years or older, or if they have a family history, in which case they will be taken at any age). Follow ups if there are cysts or tumors, then there will be further testing. Partnership with Mayo clinic for further diagnosis, and any and all treatment. Fully paid. Someone in the household must be gainfully employed. Must not have health insurance. Must not have Shands card, Medicaid, or Medicare. Must live or work in Duval. http://vim-jax.org/wordpress/ Walk of Hope Boutique The Walk of Hope, located on the second floor entrance of the Mary Virginia Terry Cancer Center, connects cancer patients with products, services, and support needed most during their journey with cancer and beyond. http://www.jaxhealth.com/services/cancer/services/walk-of-hope/ Way Free Clinic http://www.thewayclinic.org/ WE CARE Program There are multiple clinics around Duval County. These provide free primary healthcare, and follow up care to the poor and underinsured of Duval. Patients must be resident of Duval County, 30 must be have any health Insurance, and must meet financial guidelines based on size of household. Department of Health’s income guidelines are set at 200% of the U.S. Government poverty level http://www.wecarejacksonville.org/index.php?/about Yoga Survivors Coalition http://www.youngsurvival.org/ 31